On AIDS: Three Lessons From Africa

An AIDS fable: Once upon a time, in the years after AIDS went from being a death sentence to a manageable disease, at least for people rich enough to take antiretroviral therapy, many of the people who ran the world believed that these medicines weren’t appropriate for residents of very poor countries. Even leaving aside the cost, they thought that poor people couldn’t take their medicines on time. Andrew Natsios, the head of the United States Agency for International Development in the George W. Bush administration, argued against funding antiretroviral therapy in Africa. “People do not know what watches and clocks are,” he told the Boston Globe in June, 2001.

The Bush administration got over that idea, and established the President’s Emergency Plan for AIDS Relief — the greatest achievement of the Bush presidency. And the United States is also the major contributor to the Global Fund to Fight AIDS, Tuberculosis and Malaria. In large part because of these programs, which bought generic medicines in enormous quantities, the cost of AIDS therapy has dropped by 99.5 percent. Triple therapy had been $15,000 per year or even more; now some three-drug combinations are $75. And, as we heard at the biennial global AIDS conference in Melbourne last week, AIDS treatment is also AIDS prevention: people who take these medicines consistently are 96 percent less contagious. The treatment that is saving lives has also significantly cut the spread of H.I.V.

But the key word is “consistently.” The viral load of H.I.V. in the blood has to be zero, or near zero. Was Andrew Natsios right when he said that Africans would fail?

At Fixes we’re interested in what separates success from failure. We’re especially interested in positive deviants — the people, places and institutions that are doing much better than others with the same resources. What are they doing that others are not? And what can we learn from that?

In honor of the AIDS conference, I’m looking this week at three different — and surprising — positive deviants, countries that are doing very well on some aspect of fighting AIDS. The first is Rwanda, one of the world’s poorest countries. (I had data help from Nancy Fullman of the Institute for Health Metrics and Evaluation, who gives her take on Rwanda here.)

Rwanda’s Medicine Monitors

Lots of people everywhere, including in Africa, don’t take their AIDS medicines correctly, putting themselves and others at risk. Very few of them, however, live in Rwanda. Researchers measured the viral load of people in Rwanda getting antiretroviral therapy: 83 percent of them had an undetectable viral load.

The United States does a few percentage points worse. Rwanda also does better than the United States on getting antiretroviral therapy to those who are diagnosed as needing it — 91 percent have it in Rwanda, 75 percent in the United States. In America, 33 percent of H.I.V.-infected people get antiretroviral therapy. In Rwanda, it’s 54 percent, according to the United Nations database AIDSInfo (it’s probably higher now).

How does Rwanda do such a good job of getting medicines to its people — and having them take the medicines correctly?

The two most important reasons are common to virtually all countries that are successfully treating AIDS: strong political will to improve health, and a push to spread health care as widely as possible. “Eleven years ago a handful of people were getting care in Rwanda— all of them paying expenses in the city,” said Dr. Paul Farmer, the founder of Partners in Health, which works extensively in three districts of Rwanda and helped the health ministry develop its national plan. For the very poor, he said, “a round trip bus to go to the city is equivalent of a business class airfare from Boston to Los Angeles.”

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Beginning in 2006, however, Rwanda began building clinics and hospitals all over and invested in management systems to make drugs more consistently available (although availability is still a problem). The country hired and trained 55,000 community health workers. “Once you have a good supply chain, you know drugs are in the patient’s hands,” Farmer said. “That doesn’t mean they’re in the patient’s bloodstream. But if you have village-based accompaniment, you remove a bunch of barriers to adherence. Someone asks how you’re feeling. Someone sits with you and talks to you. Critics say it’s intrusive. But people like it when they say, hey, I care about you and I’m making sure you take your medicine.”

Ethiopia’s Community Conversations

Many countries are seeing a large drop in the rate of new H.I.V. infections — Nepal and Cambodia are two of them. But the most impressive drop belongs to Ethiopia — it’s the country with the biggest AIDS burden and the fewest resources. Between 2001 and 2011, the rate of new infections in the country dropped by 90 percent (PDF, Page 11).

How did Ethiopia do it?

As with Rwanda, improvement in AIDS care is part of a general improvement in healthcare, especially in maternal-child care. And Ethiopia, like Rwanda, has increased its health budget and built new clinics and hospitals. In 2003 it started a health extension program, which has trained and employed 30,000 health extension workers. Ethiopia also greatly increased male circumcision in Gambela, the one district where it was not widely practiced.

But Ethiopia’s secret weapon — a practice no other country is using on a national level — is community conversations.

These were started by an Ethiopian woman, Bogaletch Gebre, as a way to build popular opposition to female genital cutting. They have been hugely successful, largely eradicating the practice in the region where Gebre works. Now they are used in villages and schools everywhere to fight H.I.V. In 2012, the Joint United Nations Program on H.I.V./AIDS noted in its country report on Ethiopia that in 2010-11 alone, almost 90 percent of local governments had successfully conducted community conversations.

Community conversations are guided groups of 50 people who meet over and over again to talk through issues and gradually reach a consensus. They have rapidly spread the word about H.I.V. “It’s amazing how much has moved in a short time,” said Luiz Loures, the deputy executive director of program for UNAIDS. “From almost no knowledge about H.I.V. to very high levels compared with other countries.”

But knowledge, of course, isn’t the same as behavior change. Loures said the community conversations helped that process to happen. “People talking to people — that’s the game changer. Knowledge moved from a patronizing way to put it inside the community.” Ideas about what to do didn’t come from outsiders. They were developed and embraced by the community.

Loures said that one high-risk group that benefited was girls. Sex between older men and young women is an important driver of the H.I.V. epidemic in Ethiopia — as elsewhere. Girls are usually instructed to resist the sugar daddy or negotiate condom use — both very difficult to do. Loures said the community conversations put the community behind the girl, giving her bargaining power.

Malawi’s Plan B (Plus)

Like many other nations, in 2011, Malawi was rolling out a nationwide plan to save babies from getting H.I.V. from infected mothers. At the time, the World Health Organization recommended putting H.I.V.-positive pregnant women on full antiretroviral therapy, for life, at 14 weeks gestation if their number of infection-fighting CD4 cells in their blood was below 350 per millionth of a liter. If their CD4 count was higher, however, the W.H.O. recommended one of two other antiretroviral drug regimens, labeled Option A and Option B — countries could choose which to promote. Both were temporary, stopping when breastfeeding ended.

This was a problem for Malawi. Finding out CD4 counts required lab equipment. Women were, of course, having babies all over the country. But Malawi didn’t have laboratories all over the country. So Malawi decided to dispense with the CD4 count and start all H.I.V.-positive pregnant women on lifelong antiretroviral therapy — a strategy that has come to be known as Option B+.

Many people thought this was crazy. It meant that every single health clinic that did prenatal care now had to stock large quantities of antiretrovirals and have the ability to prescribe and administer them to patients — for life. The vast majority of these clinics had no doctors. And Malawi already had plenty of challenges: clinics often ran out of H.I.V. testing kits or the course of medicine for pregnant women.

But Option B+ has succeeded. In part because of it, Malawi cut the number of new H.I.V. infections among children by more than half from 2009 to 2012. That’s one of the best records in the world at saving babies from AIDS. And Option B+ also helped mothers. In the year following its debut, the number of pregnant or breastfeeding women starting antiretroviral therapy went up 748 percent (not a typo). Option B+ is now the W.H.O.’s recommended strategy.

How did Malawi do it? It trained thousands of health care workers — almost none of whom were doctors — in how to treat AIDS. It gave nurses the ability to prescribe the drugs. Putting pregnant women on the standard antiretroviral therapy simplified procurement, supply, training and other management issues. In December 2011, the drugs were available in 303 clinics. Eight months later, they were in 647 clinics.

Doubling the number of places with access to AIDS medicine helped everyone. “By rapidly decentralizing antiretroviral therapy to do Option B+, you’ve made it available to communities everywhere,” said R. J. Simonds, vice president of program innovation and policy at the the Elizabeth Glaser Pediatric AIDS Foundation, which works in 15 countries to prevent mother-to-child transmission of H.I.V.

Option B+ still has big challenges. It’s expensive — although the short-term costs of putting more people on therapy is probably a long-term savings. Many sites can’t track and monitor patients, and a large number of women quit care. Malawi had very little time to show communities why the medicines mattered, and some women threw away their pills, due to stigma or because they had no symptoms.

But it also solved many problems. Women in Malawi give birth on average to more than five children; now they no longer hop on and off therapy with each pregnancy. And permanent therapy protects subsequent children — even if mothers don’t start prenatal care until late in the pregnancy.

Option B+ will also leave fewer children orphaned. Evidence is increasing that starting people on antiretroviral therapy as soon as they are diagnosed — called test and treat (PDF) — improves health. “This is going to be the leading edge to test and treat,” Simonds said. “And Malawi just did it. They were unique in bucking the World Health Organization and coming up with this strategy — and it’s now the strategy.”